Ask Dr J – Issue 175 – Dust in your gun, and things that go POP!

By Dr Julian Saunders

DUST IN YOUR GUN

The morning after a day of hard gym bouldering, I noticed a popping or mild locking in my left middle finger when opening and closing it. The feeling soon went away, but came back worse every consecutive morning. I took two weeks off from climbing and my finger was feeling good, so I climbed very moderately two days ago, but this morning the popping returned. Any suggestions?

Jay | rockandice.com Forum

This aptly named condition, Trigger Finger, is a cyst that forms in one of the flexor tendons near the aperture of the flexor sheath. The cyst gets caught inside the sheath, hence the locking sensation, which suddenly releases when you forcibly extend the finger.

Normal function prevails until you flex it such that the cyst pops inside the aperture and becomes stuck again. Akin to having dust in your gun, it will work most of the time but don’t count on it. Typically it is worse in the mornings when fluid has had time to accumulate. Not being able to reproduce the locking sensation after flexing your finger in the morning is fairly normal.

Once the cyst has passed in and out of the aperture of the flexor sheath several times fluid within the cyst is squeezed out, or at least the dimensions alter to allow silky smooth sliding action. You may notice a small lump in the base of your finger if you palpate at the same time as flexing and extending your finger. It will feel like a 1- to 2-milimeter pea. I have had little luck treating Trigger Finger.

There is a reasonable argument that some manual therapy to try and offload stress on the cyst might help. Its effectiveness, though, seems only slightly less random than Reiki. Certainly the acupuncturists I have spoken with indicate they have had success, so that may be worth a try. Anti-inflammatory medication does very little. The same goes for taping/immobilization. In fact, the latter will often attract a few additional problems and is generally just a pain in the proverbial. Your climbing should be unaffected as long as the locking sensation is just in the morning. You are certainly not doing any significant damage by continuing to climb. It will just be annoying.

Sorry I can’t give you a fix-it recipe. Western medicine has very little to offer you. Usually the problem goes away with time. If it gets really troubling, surgery may be an option, though it is not one I would take lightly.

RETRO SHOULDER

I’ve been diagnosed with a grade 3 AC joint separation from a mountain-biking accident. I’m 42 and a serious social rock climber. I’ve had one orthopedic surgeon recommend I have the operation and another recommend against it. What say you, Dr. J?

David Rogers | rockandice.com Forum

Do it! The boney lump on top of your shoulder is actually a joint between your collar bone and shoulder blade. More commonly known as the AC joint (acromioclavicular), it is the one joint connecting your arm to your body. And now it is not there. Shit. Get that puppy stitched, stapled, lashed, lassoed and retro-bolted back in place. The operation can cause some biomechanical issues.

For an active person these are far less than the potential problems if the joint is left separated. If you are inactive and choose not to have the op, you will suffer every now and again over the years, but the most notable problem will be early joint degeneration (osteoarthritis) in and around the shoulder. If you are a climber and decide against the operation you will likely be in an asylum for pathological frustration within a few years.

Don’t risk your safety or that of your neighbors—cancel your gun license and hand in your nail clippers. Your shoulder behaving reasonably without an operation is about as likely as Sarah Palin being given an honorary doctorate in feminist theory.

POPPING THINGS

I was pulling on a small side pull in an open-handed grip with marginal feet and heard a loud pop. After that my left ring finger felt unsupported and I couldn’t weight it. There was a dull ache between the middle and last joint of my finger, which has since subsided to a slight pain. If it is a rupture of the A3 or A4 pulley [the slips of tissue that hold the flexor tendons close to the bones], is it necessary to see an orthopedic surgeon? Can I just go skiing for the winter and forget about it?

Adrenalated rockandice.com Forum

Oh, joy, popping noises. This typically indicates the full monty of pulley damage. Though one rupture is foire standard, it is quite possible to rupture several: KA POW!

If it is A4, it is impossible to protect with taping, and climbing is not advisable for a good month or so. The A3 is easier to protect, hence the prospect of climbing is more tenable (see Bum Wraps, the truth about finger taping; No. 148).

Reconstructive surgery? Don’t bother. Anecdotally, surgery doesn’t appear to offer more than conservative treatment. I have seen climbers rupture A2, A3 and A4 in one foul interplanetary misalignment, and still return to their previous redlining best, plus some (and I am talking well into the 5.14 grade, or above V13).

Go and chase some snow bunnies if you haven’t caught one already. Do a little skiing and start back slowly next season.

CRACK HEAD

I have been climbing for seven years. Two months ago I was working an overhanging crack on toprope. My left hand was jammed in a bottleneck constriction, and as I was reaching up with my right hand for another hold, my feet came off. I fell with full force onto my left arm, but my left hand did not come out of crack. I felt a pop followed by intense burning pain in my shoulder. I saw an orthopedic surgeon (OS), and had an MRI that indicated probable cartilage (labrum) damage. The OS prescribed two months of physical therapy and no climbing. I did my two months of PT, working very hard on my own as well. The physical therapist and OS cleared me to try climbing again. I warmed up on a 5.9 crack, then a 5.10c sport climb and felt good. I woke up the next day unable to lift my left arm past the height of my shoulder due to pain. I was in a lot of pain for several days and finally went and saw another OS for a second opinion. He feels that I need surgery. What do you think?

Crimp7 | rockandice.com Forum

Just the thought of swinging around no feet with one hand jammed is enough to put me off crack climbing for life. If there is one mechanism for cartilage damage, that would have to be it.

The course you have taken is quite a good one. As far as climbers are concerned, you have done well.

It is difficult to know whether the aggravation is related to a SLAP lesion or a climbing related load on a joint that had forgotten what climbing is. In the absence of overt locking, I would be disinclined to have surgery. The pain you describe smacks of bursitis.

Not being able to lift your arm above your shoulder, though acute, is not a great sign that surgery is required. It is possible that the climbing has annoyed a tendon or bursa, both of which are exceedingly capable of rendering you a blubbering mess. I would be inclined to do some fairly vigorous stretching and try to climb again. One easy and very effective stretch involves putting your hand palm out in the small of your back, and lever your elbow forward. Hold it for 30 seconds and repeat a few times. Surgery is not urgent in this case, though may help your mental state—not to underestimate that!

Orthopedic testing in the shoulder is notoriously unreliable. The “empty can test,” mentioned in a Rock and Ice forum post, is positive for supraspinatus tears, impingement, infraspinatus tears, SLAP lesions, bursitis, AC joint strain, brain tumors, ingrown toenails and whether your stocks will bounce back this week. The only thing this test can reliably say is that there is something wrong with your shoulder.

Cartilage damage is the pink T-Rex in the doctor’s office. Notoriously difficult to evaluate using orthopedic tests, it is also often under-diagnosed in MRIs. Additionally, a labral pathology is rarely a stand-alone injury. Rotatorcuff tears often ride shotgun and discharge more than their quota of ammo.

A brief word on other stuff: Look out! Despite a committed effort by The Skeptics Society the planet remains polluted with new-age voodoo. Cancer is controlled by the mind— didn’t you know? Asbestos is just a gargantuan red herring. And injecting salt water into your labrum (that’s in your shoulder, not your vagina) will render it new again. Bullshit. Call me an unenlightened heathen and log complaints at www.nudierudie-emperors. com. The idea that Cortisone is a treatment option needs to be largely deleted from medicine’s collective conscience. Dr. Phil is also proving as hard to remove as a skid mark on sheer silk.